3 INTRODUCTION Congratulations! You have chosen a premier orthopaedic team to conduct your shoulder replacement! The University of Florida Orthopaedic Surgery program first began in 1960 as a division of the Department of Surgery. In 1975 the Division of Orthopaedic Surgery achieved full departmental status. From our beginning in 1960, the University of Florida Orthopaedics and Rehabilitation program has earned a reputation for excellence in research, teaching and clinical care. Our commitment to patient health care motivates every aspect of our efforts, from the bedside, to the classroom, to the research lab. The foundation of our department is built on two outstanding institutions: the University of Florida, a top 20 public university and UF Health Shands Hospital, one of the Southeast s premier health systems. Your doctor has explained your procedure, and what to expect post surgery. The purpose of this guide is to provide you with more information as to what to expect along the road to recovery, and what you can do to prevent any complications and maximize your outcomes. Although the healthcare team will assist you in your recovery, YOU AND YOUR FAMILY are the most important members of the team. We believe knowledge and preparation as to what to expect pre- and post-operatively will make your recovery easier. If you have questions along the way, be sure to ask them. We are here to help you achieve your goals and want you to be satisfied with your entire experience. Our goal is EXCELLENT service, from start to finish. So, let s begin.

4 TOTAL SHOULDER ARTHROPLASTY When shoulder replacement surgery is performed, the ball is removed from the top if the humerus, or your upper arm bone, and replaced with a metal implant. This is shaped like a half-moon and attached to a stem inserted down the center of the arm bone. The socket portion of the joint, or your glenoid fossa, is shaved clean and replaced with a plastic socket that is cemented into the scapula. The scapula is what you would call your shoulder blade. These implants are shaped so that the shoulder joint will move in a way that is very similar to the way the joint moved when it was healthy. REVERSE TOTAL SHOULDER ARTHROPLASTY With the Reverse Shoulder prosthesis, the anatomy, or structure, of the healthy shoulder is reversed. The implant is designed so that the ball portion is attached to the scapula and the socket is placed at the upper end of the humerus. The reverse shoulder prosthesis is primarily utilized for patients with insufficient rotator cuff musculature.

5 ANATOMY Ball and Socket of Healthy Shoulder Joint Surfaces In a healthy shoulder joint, the surfaces of these bones where the ball and socket rub together are very smooth and covered with a tough protective tissue called cartilage. Arthritis causes damage to the bone surfaces and cartilage. These damaged surfaces become rough and will become painful as they articulate, or rub together, on one another. Arthritic Shoulders Arthritis can be treated in different ways. There are medications for arthritis, exercises, and Physical Therapy and Occupational Therapy that can be done to help conservatively manage your arthritic pain. Surgery is another way to manage arthritis that has become dehabilitating. A total shoulder replacement surgery is one such surgery. Your orthopedic surgeon would help you to determine if this is the right avenue for you to follow. The surgeon will perform a comprehensive exam to include: a complete medical history, x-rays, assess your range of movement and level of daily function, and other tests to show the extent of damage to the joint. Total shoulder joint replacement will be considered if other treatment options will not relieve your pain and disability. It is important to understand the shoulder joint, arthritis, and the surgical procedure. Patients who have tried conservative treatments for shoulder arthritis, but have not been able to find adequate relief, may be a candidate for shoulder replacement surgery. As with any surgical procedure, patients considering the procedure should understand the potential risks of surgery, and understand that the goal of joint replacement is to alleviate arthritic pain. Patients generally find improved motion after surgery, as well as pain relief. When is a Reverse Shoulder Prosthesis Used? The Reverse Shoulder Prosthesis is mainly used for patients with rotator cuff tear, a medical condition in which the muscles around the shoulder joint have degenerated, or weakened to a point where they can no longer hold the shoulder joint intact or allow it to function normally in conjunction with arthritis. Arthritis, a previous shoulder injury such as a shoulder fracture, rotator cuff tear, and/or failed previous shoulder surgeries could all warrant a Reverse Total Shoulder Arthroplasty. There should be no shoulder movement initially following a Reverse Total Shoulder.

6 WHAT SHOULD I BRING TO THE HOSPITAL? You should be fitted for your sling prior to your hospital visit. You must have this post-surgery! The therapist or nurse will help you adjust it post-surgery, but you must have it with you. The sling may be bulky, so make sure that you have shirts that are larger and button up in the front, if possible, to make it easier for you to get dressed. You will need good walking shoes, or slippers with backs on them and a rubber sole. You want to do plenty of walking while you are in the hospital. Bring a robe or clothes that button up in the front. Make sure you have a current list of your allergies and medications. If you are having your dominant side operated on, remember that things will be difficult for you to maneuver and you will need some help at home. Also, any personal grooming items that you may want to pack, including hairbrush, toothbrush, deodorant, razor, shaver, eyeglasses/contacts, undergarments (for women, a bra that clasps in front or a tank top that can be cut down the side if needed for reverse TSA) and loose fitting button down the front clothing, items are preferred. If you normally use a cane, bring it with you (please properly label) or have your family bring it the morning after surgery. Before you leave your home Arrange transportation prior to admission since YOU CANNOT DRIVE YOURSELF HOME and your surgeon will let you know when you are able to resume driving again, typically after 4-6 weeks. Think about who will be able to assist you with meal preparation, medication management, self-care and exercise (if indicated by your surgeon) for the next 4-6 weeks. - If you have Medicare for your insurance and there is no skilled need in the home (this means physical therapist or a medical need for a nurse, you likely will not receive homecare). Medicare does not pay for a home health aide to come out and help you without a skilled need in the home. That is why you need to make arrangements prior to your surgery to have family or friends assist you when you get home. - If you have private insurance, most of these do not pay for a home health aide, so please make sure you know your benefits. - Going to a nursing home or rehab facility is usually not an option. There are exceptions but you need to call the doctor s office prior to surgery and talk to someone about the fact you will require placement. - The doctor s office has access to the case manager and confer with him/her regarding nursing home placement and if it will be paid for by insurance (Private, Medicare, Medicaid). Someone will get back to you before your surgery regarding this issue. At that time you can make a decision whether to go on with the surgery as scheduled or postpone until you have someone to take care of you if a nursing home is not an option. It is not the doctor s responsibility or the hospital to make sure you have someone at home to assist you after discharge. Also, remove any throw rugs or objects that may block your path.

7 WHAT SHOULD I BRING TO THE HOSPITAL? (continued) Plan on a family member, caregiver or other support person to be present at the hospital to learn how to perform exercises (if indicated), assist with upper body dressing and learn your precautions post-operatively. ANESTHESIA AND YOU You will see an anesthesiologist and/or an anesthesia nurse practitioner before your surgery. He/she will review your medical history and perform a brief physical exam. The anesthesiologist will discuss with you the options you have for anesthesia during your surgery. Keep in mind your anesthesiologist, based on your history, physical exam, type of surgery and other factors, may suggest one particular anesthetic technique. This is a copy of the pain scale used to help you communicate your pain level. Cervical plexus block and cervical paravertebral block (shoulder and upper neck) The most common nerve block used for shoulder replacement surgeries are the cervical blocks. These blocks have revolutionized early mobility of the shoulder for the Total Shoulder Arthroplasty. These blocks allow for post op day 0 activity of the shoulder when the procedure allows for shoulder activity, and helps keep pain under control to improve your comfort and your ability to rest. The packs are portable and are taken home for continued pain control. There can be side effects, as listed below, but these are temporary. When using the cervical paravertebral approach, the catheter is better anchored because it passes through multiple layers of muscle and vital anterior structures have less risk of being injured.

8 PATIENT INSTRUCTIONS: UPPER EXTREMITY CATHETERS You may receive local anesthetic through a small tube located near the nerves that go to your arm or shoulder. This medication will help your pain after surgery. The catheter (tube) has been placed by your anesthesia doctor at the request of your surgeon. About this technique of pain control: The local anesthetic medicine will not usually take away all of your pain, so it is expected that you will use some of the pain pills prescribed by your doctor while you have the catheter in place. Communication is essential to making this therapy work. Your anesthesia doctor will call you on the night you have had your surgery and each day you have your catheter in place. It is important we speak to you each day so that we can make sure that you are doing well and to see if you need any adjustments to your infusion. You will be receiving about a teaspoon of local anesthetic, numbing medicine continuously every hour. You can also give yourself additional medicine by pushing the bolus button located on the front of the pump. You can press the bolus button as often as you want to, but it will only give you the extra medicine once every minutes according to how your doctor has programmed your pump. Therefore, if you still have pain 20 minutes after pressing the bolus button, you may take your oral pain medication as prescribed. Usually about 10 to 15 hours after surgery the intense numbness that you felt initially wears off and you may experience some pain. When this occurs, take some of your pain medication and press the bolus button on the front of your pump. This will give you a small amount of additional local anesthetic medicine. After the dense nerve block goes away, most patients describe their fingers as feeling fat. However, you should be able to move your fingers and have some feeling in them, they just may not feel normal to you while the catheter is in place. The thumb is usually the digit that feels the most numb for the longest time. An example of a portable pain catheter

9 SLING TIPS FROM REHAB Most important tip... BRING IT WITH YOU if you received one at pre-op. After surgery, wear your sling at all times, unless otherwise instructed for exercises and hygiene. During your hospital stay, you will receive information specific to your type of sling, surgery and surgeon. No pushing or pulling with operative arm. Depending on your type of surgery or the surgeon, you will be wearing the sling for 4-6 weeks. GENERAL DISCHARGE INSTRUCTIONS You will receive instructions specific to your surgery postoperatively. Dressing - Move clothing to arm, not arm to clothing - Wear clothing a size or two larger than normal - Often front button down shirts are best or loose v-neck types - Therapist will demo dressing techniques during hospitalization Remember no movement of shoulder! Sleeping - Initially may be more comfortable sleeping in recliner chair - No pushing up from bed or a chair with operated side - Exit/enter bed from non-operated side - Do not place additional pillows behind upper arm Okay to place below lower arm as long as not forced into hike/elevation Swelling - Ice may be used up to 6-8 times a day No more than minutes at a time Do not use until nerve block removed Hygiene - Discuss bathing and your surgical dressing with your surgeon - Sponge bathing recommended for first two weeks to protect shoulder and remain in sling - Avoid water or products (powders or lotions) near incision - Do not shave underarms on operated side before 2 week follow up Assistance - If you live alone or your dominant side shoulder has been operated on, you will need extra help for the first week - Think about who can assist you with transportation, meal preparation and household activities as needed - If you normally use a cane, do not use it with your operated arm - Also, do not use a walker or other two-handed device

10 DISCHARGE INFORMATION KNOW the discharge language... Patients, family caregivers and healthcare providers all play roles in planning for discharge. It is a significant part of the overall care plan that many patients and care givers do not understand. Careful attention to the discharge plan and post hospital care ensures your successful surgery. Many types of post hospital care are not covered under insurance. Here are the basics. Insurance type and medical recommendations both play a role in the type of final discharge plan. Medical staff, Case Managers and Physical Therapists can recommend the appropriate level of care, insurance policies direct care based on coverage and contracts with companies. This can impact your choice of facility and amount of care you are eligible to receive. After joint surgery, patients are discharged to a variety of locations based on their general state of health, how will they recover from surgery, their assistance at home, and their insurance policies. Inpatient Rehab Hospitals are facilities such as UF Health Shands Rehab, or Brooks Rehabilitation in Jacksonville, Florida. To be admitted to these types of facilities, you need a recommendation from physical therapy for intensive therapeutic management of three or more hours per day and have medical needs that require ongoing doctor s supervision. This is most like residing in a hospital. Most orthopedics-planned joint replacements do not discharge to these types of facilities. Medicare, Medicaid and some private insurances cover this type of care. Many private insurances have a very limited benefit for this type of care. Skilled facility, Subacutes, SNF or sometimes skilled nursing facilities or extended care facilities To be admitted to these types of facilities, you need a recommendation from the physical therapist for sub-acute rehab. These facilities have both short-term recovery areas and longterm residential areas where patients receive care. These facilities have physical therapists, occupational therapists, separate therapy gyms to assist with rehabilitation; they also provide nursing care, custodial care, and can accommodate a longer stay for patients. Many orthopedics-planned joint replacements do discharge to these types of facilities. Patients that need additional assistance with walking, more time to recover from surgery, have steps or live in a difficult to reach area, or live alone, often discharge to a sub-acute facility. Is this covered by my insurance? Medicare and private insurances cover this expense; however, most private insurances or Medicare advantage plans require you to go to a facility in their network and a copayment.

11 Home Care DISCHARGE INFORMATION (continued) Home care is a visit by a medical professional including a visit by a nurse to assess, physical therapist or occupational therapist. All planned joint replacements receive some type of homecare to assist with mobility. You will be asked to choose a Home Care agency. Medicare and private insurances cover this expense, there are restrictions on the company that your insurance allows you to choose from, and you will be provided with a list of companies that are available within your network. DME This stands for durable medical equipment and includes walkers, wheelchairs, crutches, bedside commodes, and other items to assist with your mobility and care. Most insurances cover the above items, however, they do not carry specialty items such as shower chairs, slide boards or hand rails. Outpatient Rehab This is therapy that you will receive in an outpatient clinic. Most insurances cover this service, although you may have a limited choice or area that you must choose from.

12 SUMMARY OF ACTIVITY POD 0 or day of surgery Mobility Goals: Get out of bed to the chair Walk with assistance Use the bathroom with assistance You should expect to be out of bed once you are awake and alert enough to do so. You are encouraged to walk with therapy or nursing and eat your meals out of the bed. You will have a regular diet Your sling will be checked for fit and comfort A pillow can be placed under lower arm to prevent your shoulder from overstretching You should have restrictions to shoulder movement, so follow these instructions carefully POD 1 Mobility Goals: Get dressed, up for meals, walk in hallway and get ready for home You should be getting dressed, up walking, and getting ready for discharge home You will be having a PT/OT come in to review precautions, restrictions, and any exercises you are allowed to do, depending on what type of surgery you had done Thank you for choosing UF Health for your elective surgery. We appreciate your business, and wish you years of comfortable mobility!

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